Opportunity lost: End‐of‐life discussions in cancer patients who die in the hospital

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/98330/1/jhm1989.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98330/2/jhm1989-sup-0001-SuppInfo.pd

The Application of IMPACT in the Elderly with TBI

Background: The International Mission for Prognosis and Clinical Trial Design in TBI (IMPACT) prognostic models have been used to predict outcome following traumatic brain injury (TBI). These models were derived in a cohort primarily composed of randomized controlled trial participants and may not be valid for older patients seen in clinical practice. Patients and Methods: Using data from the National Study on Costs and Outcomes of Trauma (NSCOT) we identified adult patients presenting to US hospitals between July 2001 and November 2002 with non-penetrating moderate or severe TBI (GCS ≤12). The cohort was split into older (65-84 years) and younger (18-64 years) age strata and the predicted risks of death and unfavorable outcome were calculated using the IMPACT core and lab models. Model calibration and discrimination in the older stratum was compared to that in the younger stratum. Results: We identified 202 older patients (weighted n = 268) and 613 younger patients (weighted n = 1,682) with moderate or severe non-penetrating TBI. Older patients more commonly had multiple co-morbidities and used antiplatelets or anticoagulants prior to injury. Older patients were more frequently injured in a fall and three times more likely to be dead within 6 months of injury. IMPACT model discrimination did not differ significantly between older and younger age strata and was generally adequate (c-statistic for the core model predicting death by 6 months, 0.81 [0.77 – 0.84] versus 0.75 [0.66 – 0.84], respectively; p=0.26). IMPACT model calibration was poor for both older and younger strata (Hosmer-Lemeshow p-value for the core model for death by 6 months was 0.01 versus <0.0001, respectively). Pre-specified qualitative graphical evaluation suggested substantial under-prediction of mortality in the oldest decades of life but not among younger patients. Discussion: The examined IMPACT prognostic models demonstrated adequate discrimination but poor calibration in both older and younger strata of a population-based sample of patients with moderate-to-severe TBI. These models should be used with caution when stratifying geriatric TBI populations for the purposes of risk adjustment or clinical trial design.Non UBCMedicine, Faculty ofMedicine, Department ofReviewedFacultyResearche

The Application of the CRASH-CT Prognostic Model for Elderly Adults with Traumatic Brain Injury : A Population-based Observational Cohort Study

Objective: To examine the performance of the Corticosteroid Randomization After Significant Head injury (CRASH) trial prognostic model in older patients with traumatic brain injury. Setting: The National Study on Costs and Outcomes of Trauma cohort, established at 69 hospitals in the United States in 2001 and 2002. Participants: Adults with traumatic brain injury and an initial Glasgow Coma Scale score of 14 or less. Design: The CRASH-CT model predicting death within 14 days was deployed in all patients. Model performance in older patients (aged 65-84 years) was compared with that in younger patients (aged 18-64 years). Main measures: Model discrimination (as defined by the c-statistic) and calibration (as defined by the Hosmer-Lemeshow P value). Results: CRASH-CT model discrimination was not significantly different between the older (n = 356; weighted n = 524) and younger patients (n = 981; weighted n = 2602) and was generally adequate (c-statistic 0.83 vs 0.87, respectively; P = .11). CRASH-CT model calibration was adequate for the older patients and inadequate for younger patients (Hosmer-Lemeshow P values .12 and .001, respectively), possibly reflecting differences in sample size. Calibration-in-the-large showed no systematic under- or overprediction in either stratum. Conclusion: The CRASH-CT model may be valid for use in a geriatric population.Non UBCMedicine, Faculty ofMedicine, Department ofReviewedFacultyResearcherGraduat

The application of IMPACT prognostic models to elderly adults with traumatic brain injury: A population-based observational cohort study

<p><i>Objective</i>: To examine the performance of the International Mission for Prognosis and Clinical Trial Design in Traumatic Brain Injury (IMPACT) prognostic models in older patients.</p> <p><i>Methods</i>: Using data from the National Study on Costs and Outcomes of Trauma (NSCOT), this study identified adult patients presenting to US hospitals in 2001 and 2002 with non-penetrating moderate or severe traumatic brain injury (GCS ≤ 12). IMPACT model calibration and discrimination in the older stratum (65–84 years) was compared to that in the younger stratum (18–64 years).</p> <p><i>Results</i>: IMPACT model discrimination did not differ significantly between the older (<i>n</i> = 202; weighted <i>n</i> = 268) and younger strata (<i>n</i> = 613; weighted <i>n</i> = 1632) and was generally adequate (c-statistic for the core-death model = 0.81 [0.77–0.84] vs 0.75 [0.66–0.84], respectively; <i>p</i> = 0.26). IMPACT model calibration was poor for both older and younger strata (Hosmer-Lemeshow <i>p</i>-value for the core-death model = 0.01 vs < 0.0001, respectively). Pre-specified qualitative graphical evaluation suggested substantial under-prediction of mortality in the oldest decades of life, but not among younger patients.</p> <p><i>Conclusions</i>: The examined IMPACT prognostic models demonstrated adequate discrimination and poor calibration in both older and younger patients, yet particular caution may be required when applying these models to the elderly.</p

The application of IMPACT prognostic models to elderly adults with traumatic brain injury: A population-based observational cohort study

Background: The International Mission for Prognosis and Clinical Trial Design in TBI (IMPACT) prognostic models have been used to predict outcome following traumatic brain injury (TBI). These models were derived in a cohort primarily composed of randomized controlled trial participants and may not be valid for older patients seen in clinical practice. Patients and Methods: Using data from the National Study on Costs and Outcomes of Trauma (NSCOT) we identified adult patients presenting to US hospitals between July 2001 and November 2002 with non-penetrating moderate or severe TBI (GCS ≤12). The cohort was split into older (65-84 years) and younger (18-64 years) age strata and the predicted risks of death and unfavorable outcome were calculated using the IMPACT core and lab models. Model calibration and discrimination in the older stratum was compared to that in the younger stratum. Results: We identified 202 older patients (weighted n = 268) and 613 younger patients (weighted n = 1,682) with moderate or severe non-penetrating TBI. Older patients more commonly had multiple co-morbidities and used antiplatelets or anticoagulants prior to injury. Older patients were more frequently injured in a fall and three times more likely to be dead within 6 months of injury. IMPACT model discrimination did not differ significantly between older and younger age strata and was generally adequate (c-statistic for the core model predicting death by 6 months, 0.81 [0.77 – 0.84] versus 0.75 [0.66 – 0.84], respectively; p=0.26). IMPACT model calibration was poor for both older and younger strata (Hosmer-Lemeshow p-value for the core model for death by 6 months was 0.01 versus <0.0001, respectively). Pre-specified qualitative graphical evaluation suggested substantial under-prediction of mortality in the oldest decades of life but not among younger patients. Discussion: The examined IMPACT prognostic models demonstrated adequate discrimination but poor calibration in both older and younger strata of a population-based sample of patients with moderate-to-severe TBI. These models should be used with caution when stratifying geriatric TBI populations for the purposes of risk adjustment or clinical trial design.Non UBCMedicine, Faculty ofMedicine, Department ofReviewedFacultyResearche